Past, present and future of the surgery of the sympathetics.

Surgery of the autonomic nervous system has been used during more than a hundred years for different indications. The trend is in both parasympathetic and sympathetic surgery towards less invasive and more reversible methods. Thus in gastroenterology the bactericides have displaced vagotomies, and in sweating and blushing more and more sophisticated and atraumatic methods have emerged to displace sympathectomies. Even vagal stimulation has come forward to compete with sympathetic ablations in some indications, like depression. The side effects, and especially the late manifestation of some side effects have also raised ethical discussions of the justification of this kind of life quality or life style surgery. In this review, different indications and methods are discussed in the light of future needs and ethical demands.

Reversal surgery for reducing the side effects of ETS. A case report.

Endoscopic sympathetic surgery has become a widespread surgery for handsweating and facial blushing all over the world. There are not many side effects in the normal train of the surgery, only lower body sweating is known to happen in some degree to nearly everyone. When the side effects exceed the expectation of the patient, she may demand the reversal of the surgery due to the regrets of the side effects. To better cope with this demand, we have developed an endoscopic method to restore the continuity of the sympathetic trunks. A typical course of recovery of one such reversal case is presented.

Secondary sympathetic chain reconstruction after endoscopic thoracic sympathicotomy.

Thoracoscopic sympathicotomy by electrocautery is an irreversible procedure. Thus the indications must be meticulously considered before the final decision to operate is taken by both the surgeon and the patient. All possible side effects should be dealt with and written informed consent required. A case of an open nerve reconstruction of the divided sympathetic chains is presented. One year after the reconstruction the patient reported subjective relief of the compensatory oversweating and restoration of sweating in the face and the armpit. Reversible methods like clipping the sympathetic chain should be considered whenever feasible instead of the irreversible electrocoagulation of the sympathetic chain.

Treatment of social phobia by endoscopic thoracic sympathicotomy.

OBJECTIVE: To analyse the severity of various symptoms and the developmental life history in social phobia. To estimate the value of ETS in the treatment of chronic social phobia. DESIGN: Prospective study. SETTING: Clinic for Psychoneurology and Surgery in Tampere, Finland. SUBJECTS: Consecutive series of patients (n = 51). INTERVENTIONS: Endoscopic thoracic sympathicotomy. MAIN OUTCOME MEASURES: Qualitative ideographic inquiry. Questionnaire of the symptom severity using visual analogue scale. RESULTS: The life history included mental and physical abuse in 61%, paternal alcoholism in 26%. Four family subtypes were named: quarrelsome, cruel, alcoholic, and perfectionist. The pathognomonic symptoms of social phobia: hyperhidrosis, palpitation, blushing, tremor, and anxiety, were all highly significantly (p < 0.001) alleviated by ETS. 88% of the patients were satisfied with the result. There were no complications. CONCLUSION: ETS seems a promising alternative to conservative therapy for social phobia.

A new atraumatic and simple method of taking sural nerve grafts.

Because the sural nerve has become the most frequently used nerve as graft material in peripheral nerve reconstruction, an atraumatic method was developed for its harvesting. The nerve is easily identified in the popliteal region by stretching it slightly behind the lateral malleolus. Only two short skin incisions are needed for centrifugal liberation of the nerve. The advantages of the method presented lie in shorter operation time, a superior cosmetic result and a fairly intact nerve for grafting.

Strategies for improving compliance in hypertensive patients.

The results of the present trial, aimed at elucidating and improving the treatment situation of hypertensives, show that--within the domain of the Finnish community health centres--it continues to be unsatisfactory. The prevalence of the male hypertensives (those without treatment and with a permanent diastolic pressure level of at least 100 mmHg and those under treatment) aged 35 to 49 years, was 12.8%. Only half of them were receiving treatment and of these the treatment was adequate (diastolic pressure less than 90 mmHg) in only one case out of five. Overweight turned out to be common among hypertensives, 63.2% of them had at least 10% overweight (BMI greater than or equal to 27.0 kg/m2) while 15.7% had at least 30% overweight (BMI greater than or equal to 32.0 kg/m2). There were no differences worth noting in overweight between treated and untreated cases. With respect to tobacco smoking there was a clear difference in favour of the hypertensives receiving treatment, among whom only 26.1% were regular smokers, while the corresponding figure for untreated hypertensives were 41.7%. Within short time an improved, supervising physician-based treatment system could be seen to have led to favourable results in the treatment of hypertensive community health centre patients. The proportion of those receiving adequate treatment among subjects already under treatment prior to the screening, for instance, had become threefold within a few months.

Factitious pain and swelling of the upper arm. Case report.

After a trivial injury, a 16-year-old girl had pain, disability and oedema in her right arm. In a first operation the suspectedly entrapped ulnar nerve was anteposed, and in a second--because symptoms worsened--it was retroposed. The condition proved to be self-induced, by compression of the arm with a bandage.

Lin-Telaranta classification: the importance of different procedures for different indications in sympathetic surgery.

BACKGROUND AND AIMS: The second sympathetic thoracic ganglion has long been regarded as the most important structure in all sympathetic procedures for any indication, be it hand sweating, blushing, or social phobia. Earlier, we had found an interesting new basis for the selection of more specific methods in individual disorders. The aim of the present study was to either confirm the old theory or to bring forward a more appropriate theory for sympathetic surgery to be used as a classified method. MATERIAL AND METHODS: Altogether 193 patients were treated in Taiwan and 55 in Finland according to the new selective principle. Endoscopic sympathetic block of the second thoracic ganglion (ESB 2) was used as a method for conflicted type of social phobia or blushing for 25 patients. ESB 3 was used for facial sweating and blushing for 55 patients. ESB 4 was used for hand and axillary sweating for 168 patients. Reflex sweating was taken as the most important sign of unsuccessful surgery. RESULTS: All patients benefited of the procedure in their presenting symptoms. Four of 25 cases in ESB 2 -group and three of 55 cases in ESB 3 -group had unacceptable reflex sweating. No patient with reflex sweating was found in ESB 4 -group. These results confirm our previous findings, that sympathetic nerves innervate the human body in similar dermatome fashion as the peripheral nervous system. According to this, we organized the various sympathetic disorders into three main categories: those restricted within the head, like conflicted type social phobia and conflicted type blushing, to Group 1; those on the head and face, like sweating with or without blushing, to Group 2; and those in the hands and underarms to Group 3. The principle of different surgical procedures for different disorders of the sympathetic system are proposed: ESB 2 for Group 1, ESB 3 for Group 2, and ESB 4 for Group 3 disorders. CONCLUSIONS: We call this new classification "Lin-Telaranta classification". Not only the incidence of complication rates is lowered but also the side effects can be predicted by the Lin-Telaranta classification in sympathetic surgery.

Endoscopic sympathetic block--new treatment of choice for social phobia?

Social phobia is a neglected disorder, which can cause very debilitating consequences in patients' lives. The patients tend to isolate and suffer from comorbid disorders such as depression, other anxiety disorders, and drug and alcohol abuse. Traditional treatment methods such as medication and psychotherapy do not help everyone. A prospective, uncontrolled follow-up study with 169 social phobic patients was performed by uni- or bilateral endoscopic sympathetic block of the upper thoracic ganglia. The method is reversible by taking the compression block away, if needed. The selected patients had conservative treatment resistant social phobia according to DSM IV. Structured interview, Davidson's modified brief social phobia scale, and Liebowitz Quality of life questionnaire were used both pre- and postoperatively to assess the value of the treatment. All aspects of social phobia, both somatic and psychological, were highly significantly improved. Reflex sweating as the only remarkable side effect was less than in most series for other indications with sympathetic ablative surgery elsewhere. Endoscopic sympathetic block is recommended as the treatment of choice in severe, conservative therapy resistant social phobia.

ESB in the treatment of addiction. A case report.

Alcohol and drug addiction are common with people with psychiatric disorders and addiction problems can be primary, leading to psychiatric disorders, or secondary to psychiatric disorder. Treating the primary problem first often helps the patient to recover from the secondary problems also. We present a case of a lady with severe social phobia, who recovered from both from her social phobia and her addiction problems after ESB.

Sympathetic surgery for psychiatry. Case report.

One of the authors has, for many years, operated patients suffering from social phobias by using compression block on the sympathetic nerve (1). The Finnish health insurance system has not accepted this treatment as valid for reimbursement. We planned a research based on a design of pre- and post-surgery interviews conducted by a psychiatrist. Data collection was started in 1997. The sample now consists of 45 persons, of whom 20 have also been interviewed after the operation. The results are fascinatingly good. Only one person did not benefit from the operation. We present two illustrating examples. As a conclusion, we suggest that this treatment should be accepted as a valid treatment for patients who have found no relief to their symptoms of social phobic disorder from psychotherapies or pharmacotherapies.

Thoracic duct obstruction associated with the thoracic outlet syndrome.

A case is presented in which intermittent swelling of the face, left upper limb and both lower limbs was associated with steatorrhea. The thoracic duct was found to be obstructed at the thoracic outlet. After surgery the symptoms disappeared promptly. The value of lymphography is discussed and compared to the other diagnostic methods.

Transposition of pedicled skin flaps in the hand.

A series of 28 neurovascular island flaps are presented together with a series of three radial innervated pedicled flaps. The former method gave superior results compared to the latter. The mean follow-up period was 4.3 years. All the flaps survived and 21 of the neurovascular flaps were classified good to excellent, 4 cases gave fair results and in three cases the result was classified poor. Only one of the neural pedicled radial innervated flaps could be classified as fair whereas both of the others gave poor results. The neurovascular island flap method is regarded a valuable alternative to a tree vascularized composite tissue graft.

Early reconstruction of birth injuries of the brachial plexus.

Three patients with brachial birth palsy were operated on within 3 months after delivery. Reconstruction of the part of the torn brachial plexus was accomplished width free nerve grafts. At follow-up after an average interval of 2 years, 4 months, the deltoid, biceps, and external rotators of the upper arm were improved to a degree that could not possibly have been achieved without surgery.

Bone cysts containing silicone particles in bones adjacent to a carpal silastic implant.

Silastic implants for a wide variety of medical purposes are in current and frequent use worldwide. Only recently there have been reports of the migration of silicone to the surrounding tissues via lymphatics. In the present material of nine cases with carpal implants followed for more than two years, bone cysts developed in the surrounding bones on five occasions. The only cysts so far investigated thoroughly contained foreign body reaction, and silicone could be detected by electron probe microanalysis. A long-term follow-up is suggested whenever these implants are used.

Toe to hand transfer.

Nine patients received a toe-to-finger transfer after accidental amputation and one after a congenital defect. One led to secondary amputation due to arterial thrombosis. Seven of the 9 patients would have the operation again if needed. Five transplants were great toe-to-thumb transfers which the authors feel superior to second toe to thumb transplantations. The method seems to be useful in reconstructive hand surgery.

Evidence for sympathetic neural influence on human corneal epithelial function.

Patients with unilateral Horner's syndrome were studied to determine the influence of sympathetic innervation on the structure and function of the human cornea. There was no difference in total corneal thickness, corneal oxygen uptake rate or corneal touch threshold between the normal and Horner's eyes of these patients. Epithelial thickness, however, was slightly but significantly greater in the Horner's eye than in the normal fellow eye (P less than 0.025). When subjected to a hypoxic "Stress Test", patients with post-ganglionic lesions showed significantly more epithelial greying and microcystic oedema (P less than 0.025 and P less than 0.01, respectively) and reported seeing smaller and brighter haloes in the Horner's eye. The cornea of the affected eye of these patients also showed a significantly shower rate of deswelling in the first hour following the "Stress Test" (P less than 0.05). These findings suggest that both in the resting state and when the cornea is physiologically challenged, the sympathetic nervous system and in particular, the terminal sympathetic neuron, has a small but significant influence on the human corneal epithelium.